BCCDC TB ManualRevisedFebruary 2012

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TB ManualFebruary 2012 | For proessionals to help manage tuberculosis


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TABLE OF CONTENTS

INTRODUCTION

PURPOSE OF THE MANUAL

ROLES & RESPONSIBILITIES

SECTION I: SCREENING FOR TUBERCULOSIS7 Screening Programs or Populations at Risk14 Screening & Diagnostic Tools

17 Tuberculin Skin Test TS T

22 Radiology

25 Bacteriological Examination o Sputum

28 Flow Chart: TB Mycobacteriology

SECTION II: ACTIVE TUBERCULOSIS30 Case Management & Active Case Finding

39 Flow Chart: Management o An Active Case o Tuberculosis

SECTION III: CONTACT INVESTIGATION

41 Goals o Contact Investigation 41 Roles & Responsibilities

42 Principles to Guide Contact Investigation

44 Assigning Priority or Investigation o Contacts

46 Conducting a Contact Investigation

48 Contact Examination Procedure

52 Contact Examination in Congregate Settings

SECTION IV: PREVENTION56 Preventative Therapy

60 Riampin Preventative Treatment

62 Medication Reordering Instructions or Latent TB Inection

SECTION V: APPENDIX66 Appendix A: Glossary

71 Appendix B: Basic Facts about Tuberculosis

74 Appendix C: Medications

91 Appendix D: Pediatric TB

95 Appendix E: TB Services or Aboriginal Communities

117 Appendix F: BCG Vaccine

119 Appendix G: Tumour Necrosis Factor

121 Appendix H: Atypical Mycobacteria

124 Appendix I: TB & HIV

126 Appendix J: Multiple Drug Resistent TB

128 Appendix K: Directly Observed Therapy

131 Appendix L: Interim Guidelines or use o IGRA Studies

132 Appendix M: Molecular Diagnostic Tools

134 Appendix N: Immigration

137 Appendix O: Tuberculosis & Chronic Renal Failure

139 Appendix P: Sputum Induction

141 Appendix Q: Forms

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INTRODUCTION

This manual was developed by the physicians and nurses at TB Control to meet

the needs o those proessionals throughout the province responsible or managing

tuberculosis. It refects the changing policies and practices at TB Control which in

turn are based on current research ndings and new technology. The 6th Edition

o the Canadian Tuberculosis Standards has provided the oundation on which the

manual was organized. While there have not been dramatic shi ts in managementprinciples o tuberculosis there are some important changes that have taken place.

The intention was to create a manual that is userriendly, clear and concise and

one that will approximate any expectations that users o the manual may have.

As a Provincial Manual it provides direction to health proessionals working in

a variety o settings. As such it cannot possibly meet all the needs o each health

unit and their community. It will be incumbent upon the health centres to work

with TB Control in developing strategies to conront the challenges they are

acing, whether it is an outbreak setting or an isolated First Nations community.

It is our desire to have a manual that provides both direction and fexibility. As

tuberculosis inormation and practices are continually evolving an eort will bemade to provide timely updates to the manual and communicate these changes to

the eld accordingly. An important component o this guideline or best practice

in the area o tuberculosis control is comments rom the users. Every eort will

be made to incorporate that eedback in our ongoing upgrading o the manual to

better service health proessionals in BC.


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PURPOSE OF THE MANUAL

Bill 23 2008: The Public Health Act, Communicable Disease Regulation; Part 3

www.leg.bc.ca/38th4th/1st_read/gov231.htm#part3 requires that tuberculosis

TB be reported under schedule A. This tuberculosis manual is designed or the

use o sta designated under the Public Health Act to provide tuberculosis control

and surveillance.

The document is produced by the Division o TB Control at the BC Centre or

Disease Control BCCDC, an agency o Provincial Health Services Authority

PHSA, to act as a guide or nurses and doctors working in public health,

community health, and inection controlas well as a reerence or students,

researchers, and primary care physicians.

The Division o TB Control is responsible or the establishment and maintenance

o policies, standards and procedures or the control o TB in British Columbia. The

Canadian Tuberculosis Standards 2007 are used as guidance and adapted to meet

the specic needs within British Columbia.

The manual contains background inormation regarding the signicant

aspects o tuberculosis, the policies, standards, and guidelines or the control

and surveillance o tuberculosis, as well as the supporting documentation and

data collection tools. This manual is meant to be used in conjunction with the

Canadian TB Standards 2007. Copies o the Canadian Tuberculosis Standards

are available by contacting the BC Lung Association at 604 731LUNG 5864

or 1800665LUNG 5864 outside the Lower Mainland, or on line at

http://www.phacaspc.gc.ca/tbpclatb/pubs/tbstand07eng.php

The manual is organized to guide the reader in TB screening methods or various

high risk populations, diagnosis and treatment o active TB cases, diagnosisand treatment o latent TB, contact tracing, TB prevention and client education.

The appendices provide additional inormation, orms and resources or patient

teaching, as well as a glossary o denitions requently used in TB Control.

Recommendations or revisions may be directed to the Director o TB Control.


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ROLES AND RESPONSIBILITIES

The responsibilit y or the control o communicable diseases, including TB, lies with

the Medical Health O cer. The clinical care o an active case o tuberculosis is the

responsibility o the clients personal physician, requently in consultation with the

physicians at TB Control and with the assistance o local public health nurses and

community health nurses working in Aboriginal communities.

TUBERCULOSIS CONTROL (TB CONTROL)

TB Control provides central coordination o management and control measures

or cases, contacts, and others at risk o developing tuberculosis. This includes the

control and provision o ree medications or treatment o active disease and latent

inection. It also includes coordination o contact investigation, administration

o the provincial TB registr y database, and reporting o cases nationally. TB

Control is committed to supporting regional health authorities and Aboriginal

communities in ensuring the provisions o the Bill 23 2008: Public Health Act

and communicable disease regulations are met.

PUBLIC HEALTH

Public and community health nurses play a central role in the delivery o the

TB program in BC. In collaboration with the primar y care physician, MHO,

and TB Control they are actively involved in surveillance, contact investigation,

supervision o treatment o both active TB and latent TB inection within their

health regions. In most instances, they are the primary contact with clients

and consequently have a signicant infuence on the outcome o the treatment

program. Inormation collected in the eld by public health should be relayed to

TB Control so client care is consistent, sae and epidemiological data can be used

or uture program development.


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SCREENING PROGRAMS FOR POPULATIONS AT RISK

TB Control recommends that certain groups o the population should be screened

based on relative risk actors. Specic populations and programs selected or

screening are as ollows:

Detox Centres and Residential Alcohol & Drug Treatment Programs

Adult Licensed Residential Community Care Facilities Licensed Child Care Facilities

Correctional Facilities

Other Speciic Populations i.e. Health Care employees and Immigration

1) DETOX AND RESIDENTIAL TREATMENT CENTRES

The goal is to identiy and treat individuals with active TB disease and prevent

transmission to a vulnerable population in group settings.

RATIONALE:

Detox acilities are oten short stay settings. Thus, TB Control does not recommend

TB skin testing as it requires a reading 48 to 72 hours ater initial planting and only

indicates inection as opposed to active disease. Chest Xrays CXR, sputum collection

and symptom assessment are more valuable tools in ruling out active disease which is

the goal in screening or admission to detox and treatment centers.

TABLE 1.1: SC REENING FOR DE TOX CEN TRES AND R ESIDENTIAL T REATMENT PROGR AMS

Clients Tuberculin Skin TestTST

Chest Xray CXR Symptom Inquiry Sputum collectionor AFB 3 samples

Detox Centres

Following entry toacility

NOtypically veryshort stays anddiicult to locateclient ollowingdeparture

YES YES I abnormal CXR orsymptomatic:Collect 1 specimenimmediately, then2 additional on theollowing 2 days

Residential Drug &Alcohol TreatmentPrograms

Complete prior to entryto acility

YESunlessdocumentation oprevious positive TSTor history o active TB

disease treated

I TST is positive, orhistory o positiveTST/active TB o rshowing symptoms

o TB

YES I abnormal CXR,symptomatic, orunwilling to haveCXR: Collect 1

specimen immediately,then 2 additional onthe ollowing 2 days

Note: or employee screening, please reer to Public Service Guidelines page 9.


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2) ADULT LICENSED RESIDENTIAL COMMUNITY CARE FACILITIES

All persons who are entering a care acility, or starting employment in such a

acility, should be screened or TB beore admission by their private physician,

public health, or TB Control. Due to the challenges o screening or TB prior

to admission, a patient or employee may be screened post admission as

recommended below i they are not symptomatic. The Medical Health O icer

may make alternative policy decisions based on local disease incidence andprevalence. The Tuberculosis Screening Program Form HLTH 939 must be used

or the initial screening program. http://www.bccdc.ca/NR/rdonlyres/69DDB0EB

CC6C458C8EEC67C3899C6AD2/0/HLTH939_Feb2011.pd

RATIONALE

To minimize the risk o spreading ac tive TB disease as residents in care aci lities

tend to remain or long periods o time in an environment which would pose a

risk to both the sta and the other residents. Compared to general hospitals, care

acilities tend to have reduced levels o medical sur veillance. As many clients

have reduced mental alertness, it is important to screen the above group withinthe suggested period o time. Preventing a case o TB rom spreading within a

acility reduces the need or ex tensive contact tracing and keeps others healthy.


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TABLE 1.2: SCREENING FOR ADULT LI CENSED R ESIDENTIAL COMMUNITY C ARE FACIL IT IES *

Tuberculin Skin TestTST


Resident:Complete prior to

admission or within1 month o admissioni not symptomatic

YESonly orresidents less than

60 years o age andpreviously skin testnegative or unknown

YESor residents 60years o age and older,

or symptomatic, orhave a positive TST orpersons who have riskactors or TB

YES I abnormal CXR orsymptomatic:

Submit 3 sputa or AFB

New Employees:Complete prior toemployment or within2 weeks

YESunlessdocumentationo previous positiveTST or histo ry oactive TB disease ori TST neg in last 6months & no contactwith active case

YESi TST is positiveor symptoms o TB



* All licensed group home screening should be based on contact tracing o active cases. Routine

screening, not required.

EXCLUSIONS FOR RESIDENTS:

Where there is di culty arranging a chest radiograph at the time o

admission, the ollowing are acceptable:

A normal chest radiograph completed within one year preceding admissionor asymptomatic clients.

EXCLUSIONS FOR EM PLOYEES:

Normal CXR in the past 6 months

Pregnant employees should have CXR ollowing delivery. Contact TB Control i symptomatic

EXCLUSION FOR TUBERCULIN SKIN TEST (TST):

Previous TB

History o anaphylaxis or severe reaction to TST

Documented previous positive TST


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3) LICENSED CHILD CARE FACILITIES

Routine screening o employees o licensed child care acil ities is currently not

recommended except in Aboriginal communities as identied by TB Control.

RATIONALE

A review o our cases shows that no child had been inected as a result o exposure

to a child care worker in nonAboriginal communities in BC within the last ten

years. Screening o child care employees is logistically di cult and can be costly

due to the large turnover o employees.

The only exceptions to these recommendations are Aboriginal child care acilities

which will continue to require screening at this time. See Appendix E

NOTE:These recomm endations can be changed at the discretion o the local Medical

Health Oicer depending on local circumstances.

4) CORRECTIONAL FACILITIES

Individuals in the correctional setting are at relatively highrisk o being inected

with tuberculosis or having active disease resulting in the potential or outbreaks

in these institutions.

FEDERAL CORRECTIONAL FACILITIES

In 1994, tuberculin skin test was replaced with twostep testing. Individuals with

a positive tuberculin or symptoms are reerred or chest xray and a medical

evaluation.

PROVINCIAL CORRECTIONAL FACILITIES

There are a high number o admissions per year, with the vast majority o inmates

staying or weeks or months at a time. Inmates are assessed upon admission. No

routine tuberculin skin testing is done on asymptomatic inmates. Symptomatic

inmates are reerred or medical assessment and TB workup TST, sputum and

chest xray. Any inmate with a positive skin test should have a chest xray and i

symptomatic, three sputum specimens should be submitted or AFB.

Correction acility sta should have a baseline TST perormed when hired. Furthertesting should only be done in response to an exposure to an active case.


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TABLE 1.3: S CREENING FOR FED ERAL AND PROV INCIAL CORRECT IONAL FACILIT IES



Federal Corrections:

Inmates

YESonce or newadmissions

Repeat annually or

inmates with negativeTS T

YESor inmateswith a positive TST orreusing a TST

YES * I abnormal CXR orsymptomatic:


Federal Corrections:

Sta

YESbaseline uponemployment andannually i negativeTST

Baseline i previouspositive TST or activeTB



ProvincialCorrections:

Inmates

Not routineonly iclient is s ymptomaticor at risk or TB i.e.HIV positive

Not routine

All symptomaticinmates

YES * I abnormal CXR orsymptomatic:


ProvincialCorrections:

Sta

YESbaseline TST,unless documentedexclusions

Baseline i previouspositive TST or historyo active TB

YES

* Symptomatic inmates isolated until TB ruled out

5) OTHER SPECIFIC POPULATIONS

Health Care and Public Service Employees

Volunteers

Post Secondary Institutions

Immigration Surveillance

High Risk Individuals


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HEALTH CARE & PUBLIC SERVICE EMPLOYEES

TB Control recommends that all employees be screened or TB at the time o

hiring. The establishment o baseline data or individuals in the above groups

determines who has been inected with the tubercle bacillus and who has not.

Institutions with the classication o medium to high risk o exposure or sta may

decide to implement routine TB screening as an adjunct or substitution or contact

investigation. Once the baseline has been established, contact screening may be

more easily undertaken when necessar y.

Local conditions may be such that the Medical Health O cer and TB Control

jointly make alternate policy decisions.

It is the responsibility o institution to implement.

TABLE 1.4: SCREENING FOR HEALTH CARE AND PUBLIC SERVICE EMPLOY EES

Tuberculin Skin TestTST Chest Xray CXR Symptom Inquiry Sputum collectionor AFB 3 samples

Health CareEmployeesHospitals:

Responsibilityo institution toimplement

YESbaseline uponemployment andannually i negativeTST

Repeat TST based onexposure to activeTB or in accor dancewith acility InectionControl Committeerecommendations

based on level o riskor exposure.

YES i baselineTST positive attime o hiring, orsymptomatic

Repeat CXR i exposedto active TB



Public ServiceEmployees:

Examples include:Community/PublicHealth nurses, homecare nurses, streetnurses, police, ireighters

YESbaseline TSTupon employment

Repeat TST based onexposure to active TB

YESi TST is positiveor showing symptomso TB

Repeat CXR i exposedto active TB




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VOLUNTEERS

The need or testing is determined locally and on an individual basis.

Volunteers working with high risk populations see page 16 should ollow the

same recommendations as or public service employees.

POST-SECONDARY INSTI TUTIONS

Currently it is not our policy in British Columbia to screen postsecondary students

or tuberculosis. Exceptions to this general policy should only be made at the

discretion o the local Medical Health O cer in consultation with TB Control.

An exception to this policy is or students in health care who require baseline TB

screening prior to direct patient care.

IMMIGRATION SURVEILLANCE

Health and Welare Canada screens all persons applying or immigration to

Canada. Immigrants who have a history o previous tuberculosis, or who have

evidence on chest radiograph o inactive tuberculosis, are reerred to TB Controlupon arrival in Canada. These persons have signed a orm that states they will

comply with surveillance requirements and repor t to TB Control or assessment.

Upon receiving notication rom Health and Citizenship Canada, TB Control wil l

send notication see Appendix N page 136 to the health unit HU in which

this person resides requesting:

A health history orm 939

Chest radiograph

Three sputum specimens.

Health Units HU will locate the persons and advise them o TB Controls request

and will arrange or chest radiograph and the collection o the specimens to be

sent to TB Control. See Appendix N

I the individual is asymptomatic and does not have health coverage, the chest

xray CXR can be delayed until they are eligible or health coverage usually

within three months. I an immigrant is symptomatic requiring a CXR beore

three months they will be requested to cover the cost. In the event there is nancial

hardship TB Control will cover the cost o the CXR or those who are symptomatic.


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TABLE 1.5: SCREENING FOR POST-LANDING IMMIGR ATIO N SURVEILLANCE



Postlandingsurveillance

NO YES YES YES

HIGH RISK INDIVIDUALS

The ol lowing groups require special considerations or screening relating to

their individual risk actors. TB Control recommends TST, symptom inquiry, and

baseline chest xray or the ollowing individuals:

HIV positive

Organ Transplant

Dialysis

Prior to starting Tumour Necrosis Factor TNF inhibitor Appendix G

Street involved including; alcohol and/or substance users Followup screening based on the exposure to active TB or at the

discretion o local healthcare providers

SCREENING AND DIAGNOSTIC TOOLS

ASSESSMENT COMPLET ING HLTH 939 FORM

Proper assessment o an individual and documentation o the assessment provides

important clinical inormation which assists the clinicians at TB Control to

make a diagnosis and/or recommendations. The HLTH 939 orm is a guideline to

completing the assessment and includes the ollowing points:

Demographics

History

Contact inormation

Risk actors or developing active TB

Symptoms o active TB

The public health nurse PHN and community health nurse CHN must ensure

the ollowing inormation is collected and conveyed to TB Control by way o a

Health HLTH 939 orm or each client screened or TB See orms in Appendix Q.

http://www.bccdc.ca/NR/rdonlyres/69DDB0EBCC6C458C8EEC67C3899C6AD2/0/

HLTH939_Feb2011.pd


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TST

Indication or screening

Contraindication

Tuberculin Skin Test TSTto identiy individuals who have been

inected by tubercle bacilli see Appendix Q Decision Support

Tools TST

Chest xray i history, symptoms, and/or TST indicate necessity

3 sputum specimens submitted or AFB smear and culture i

symptom inquiry, chest radiograph and/or TST indicate necessity

DEMOGRAPHICS

Obtain personal inormatione.g. name, date o birth, sex, address, phone

number, physicians name and address, and Personal Health Number PHN

Ethnic origin

Aboriginal statuslives on or o reserve; community & health centre

Country or Canadian province o birthi patient is rom outside o Canada,

must indicate date o arrival in Canada

HISTORY

Prior exposure to tuberculosis

Previous active TB and treatment

Previous preventive treatment

Previous tuberculin tests, i any, provide results

Previous BCG, presence o BCG scar

Travel to countries which have high incidences o TB length o travel

CONTACT INFORMATION

TB number o source case i TB number not yet assigned may use PHN

Date o contact, length o contact, type o contact, location o contact

Indicate i TST baseline or 8 weeks post contact

TY PE OF CONTACT:

Type 1Household or share the same air space or more than 4 hrs/wk

Type 2Nonhousehold or share the same air space or 24 hrs/wk Type 3Casual or share the same air space or less than 2 hrs/wk

NOTE: Further detailed inormation about contact tracing will be discussed in Section IV: Contact Tracing


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RISK FACTORS FOR DEVELOPING ACTIVE TB

INCREASED RISK

Treatment with glucocorticoids or any other immunosuppressive agent

TNF inhibitors see Appendix G

Diabetes

Underweight less than 90% ideal body weight or BMI less than 20

Young age when inected equal to or less than 5

IV drug use/ crack cocaine

Homelessness

HIGH RISK

HIV/AIDS

Transplantation related to immunosuppressant therapy

Chronic renal ailure requiring hemodialysis

Carcinoma o head & neck

Recent TB inection TB contact within 2 years

TB contact within 2 years

Silicosis

SYMPTOMS OF ACTIVE TUBERCULOSIS

Cough, and/or sputum production greater than 3 weeks Collect 3 sputum on 3 consecutive days

Sputum production

Blood in sputum hemoptysis

Night sweats

Fever

Fatigue

Weight loss Loss o appetite

Chest pain

Other symptoms will depend on the site o disease


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TUBERCULIN SKIN TEST (TST)

PURPOSE: To determine whether an individual has been inected

with the tubercle bacillus as evidenced by a positive tuberculin skin test.

The tuberculin skin test TST is the main test used to diagnoselatent tuberculosis inection LTBI. This test consists o an

intradermal injection o 0.1 ml o puried protein derived rom

Mycobacterium tuberculosis bacteria. In a person with normal

immunity to these tuberculin antigens, a cellmediated, delayed

type hypersensitivity reaction will occur within 4872 hours. The

reaction will cause localized swelling and will be maniest as

induration o the skin at the injection site. It requires 3 to 8 weeks

ater an exposure or the body to mount a response and or the test

to turn positive.

A tuberculin skin test is not diagnostic o active tuberculosisdisease. Other diagnostic tools i.e. sputum or AFB, chest xray,

symptom inquiry are the principle means o screening or active

TB disease. A negative TST does not exclude a diagnosis o ac tive

tuberculosis. I symptomatic, collect 3 sputum specimens or

mycobacteriology, send or chest xray, and call TB Control or

urther advice.

INDICATIONS FOR TST ADMINISTRATION

Contacts o a patient with a recent diagnosis o active inectious TB Household, or close contacts o a patient diagnosed with extrapulmonary TB

Reverse contacts o a child diagnosed with active TB

Screening individuals prior to starting tumour necrosis actor TNF inhibitors.

Screening programs or select groups o persons judged to be at risk

i.e. kidney dialysis patients

HIV positive individuals and individuals at high risk or HIV inection

i.e. Injection Drug Users IDU. TST results may not be reliable in HIV positive

individuals with low CD4 counts less than 200.

International travelers who will be residing in countries where tuberculosis is

endemic. These travelers should have a baseline TST beore leaving Canada and

a TST on return to Canada. A twostep TST is an option in this situation at baseline testing.

Travellers returning rom visits to endemic areas

Mass screening to determine community prevalence o inection only applies to

identiied Aboriginal Communities See Appendix E

Specic populations at risk, or example: Health Care Employees see Screening section

Individuals with signs and/or symptoms o active tuberculosis, remembering that a

negative TST does not rule out TB

NOTE:Reliance should not beplaced on a previous TST thatwas not documented unlessthe person can give you aclear description o extensiveswelling, especially withblistering.


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CONTRAINDICATIONS

Persons who have had an anaphylactic response or severe reaction to a previous

TST using Tubersol, a similar product or components o Tubersol.

Persons who have a documented history o a previous positive reaction to

tuberculin testing.

Persons who have documentation o previous active tuberculosis.

Persons with major viral inections or livevirus vaccinations in the past 4 weeksto avoid alse negative reactions.

Individuals with severe burns or eczema at skin testing sites.

NOTE:

A history o a Bacille CalmetteGuerin BCG vaccine is not acontraindication or a TST.

Pregnancy is not a contraindication or a TST.

TST may be given on the same day as MMR and/or Varicella, andYellow Fever vaccine otherwise wait or at least 4 weeks.


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ADMINISTRATION OF TUBERCULIN SKIN TEST

Tuberculin skin testing is standardized by using Sano Pasteur Tubersol bio

equivalent to 5 TU 0.1 ml o tuberculin o puried protein derivative PPD,

which is supplied by the pharmacy at BC Centre or Disease Control.

Tubersol should be used as soon as it is drawn up in the syringe as the tendency o

tuberculin to adhere to plastic suraces causes marked reduction o the strength o the

solution. Sano Pasteur, maker o the PPD, recommends that the tuberculin be let

drawn up in the syringe or a maximum o 20 minutes. Tubersol should be stored in

a rerigerator 28 C and can be adversely aected by exposure to light.

PREPARATION

Ensure all equipment is readily available, including sharps container

and anaphylaxis kit.

Seat the client comortably and explain the procedure. Ensure that

the client is aware that they must return in 48 72 hours or reading.

Selreading o skin test results by the client is not acceptable.

Wash your hands. Use a tuberculin syringe with a 26 to 27 gauge needle

INJECTION PROCESS

Cleanse the skin with isopropyl alcohol unless allergic and allow to dry.

The skin o the orearm should be held taut with one hand.

Administer test intradermally on the anterior orearm, 2 to 4 inches

below the elbow see picture below.

The syringe should be held at a 5 degree angle, with bevel up.

Insert the needle just underneath the irst layer o skin and slowly

inject 0.1ml o tuberculin. You should be able to see the tip o the

needle underneath the skin and eel resistance when you inject .

A wheal or bleb 6 to 10 mm in diameter should appear.

I an elevated wheal does not appear, repeat the skin test 20mm

below the original site or the other arm. Bandaids are not recommended, but i used should be removed

30 minutes ater the tuberculin is administered.

Instruct client to remain in the clinic area or 15 minutes ater the

injection to ensure they have not had an allergic reaction.


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READING THE TUBERCULIN SKIN TEST

A tuberculin skin test should be read 48 to 72 hours ater administration by a

health care proessional trained in this skill. Selreading o skin test results by the

client is not acceptable.

Results should be recorded in millimetres mm, not as positive

or negative.

Negative skin test reactions show no mark or a small bruise around

the injection site. Some skin test reactions will show an area o

erythema redness around the injection site, but no induration can

be palpable at the site. The reaction should be recorded as 0mm.

Large skin test reactions will show an inner indurated area, which

may be blistered, surrounded by erythema. Only the inner

indurated area should be measured. The presence o blistering at

the site should also be recorded.

READING PROCESS

Support the orearm on a irm surace Mark the borders o induration by moving your inger or the tip

o a pen at a 45 degree angle transversely across the arm towards

the site o injection until there is resistance indicating an edge i

one present. Mark that edge.

Repeat on the other side

Measure the distance between the two marks with a calliper ruler

i available i not a lexible ruler can be used.

INTERPRETATION OF THE T UBERCULIN SKIN TEST

The interpretation o the tuberculin skin test depends on the reasonor testing and can rely heavily on data provided on the HLTH 939.

5 mm or greater skin test reaction is considered positive or the

ollowing groups:

Contacts o an active case o TB

Immunocompromised individuals

Individuals with HIV inection

Individuals with chest xrays compatible with

previous TB disease

IV drug users

10 mm or greater skin test reaction is considered positive or all other groups

Individuals with a positive skin test reaction should be reerred or a

chest xray. The Tuberculosis Screening Program orm, HLTH 939

when completed which acts as the chest xray requisition orm.

NOTE:A Personal HealthNumber PHN is requiredor all TB chest xrays aso April 2009.


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UNINTENDED OUTCOMES

ANAPHYLAXIS is very rare but is possible. Epinephrine Hydrochloride Solution

1:1000 must be readily available when administering a tuberculin skin test.

Follow the BC Centre or Disease Control Immunization Programs Protocol or

Emergency Treatment or Anaphylaxis. See http://www.bccdc.ca/discond/comm

manual/CDManualChap2.htm , Immunization Manual Section 5

Document in clients record

Inorm TB Control and local MHO; have vial lot # & do not throw out.

SEVERE REACTION is one with excessive swelling, pain or discomort, or progression

to the stage o vesiculation and sloughing o tissue. Severe reactions sometimes are

associated with infammation o the lymphatics draining the area red streaks in

the arm and with soreness or swelling o the glands in the axilla. This is almost

always a sensitivity reaction and should not be conused with secondary inection.

Apply sterile, dry dressing to any open or sloughing area. Cortisone ointment has

not been ound to be helpul. Reassure client about early resolution though someredpurple discolouration may persist or several weeks. Certain skin types may scar.

At the discretion o the public health nurse, reer person to personal physician.

Severe reaction should be documented on the HLTH 939 orm and in clients record.

Pain, itchiness, discomort at the site may occur, and should be treated with the use

o cold compresses. Benadryl can be eective in reducing the eect o the sideeects.

TWO-STEP T UBERCULIN SKI N TESTING

The twostep Tuberculin Skin Test identies individuals who had been inected

in the past, but may now have a decreased sensitivity to the TST. It enables oneto distinguish between what could be a booster response and a true conversion

rom a recent contact. It is useul as a baseline or individuals working in high

risk settings who will continue to be ollowed by TSTs. It can be an option in other

settings such as HIV positive in high prevalence communities i resources are

available. It should not be used or screening o contacts and need only be done

once.

Procedure or administering a 2step skin test involves completing the init ial TST

and i the TST is negative, a second TST is administered one to our weeks later.

The second one should be administered on the opposite orearm or 5 cm below

the previous site. The same techniques and principals o skin testing apply to the2step skin test.

Due to sta ng, resources and practicality, 2step testing is not generally

recommended by TB Control. Travellers, those working in corrections, and health

care workers are individuals who might benet rom 2step sk in testing when

resources permit.


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RADIOLOGY

PURPOSE: To evaluate individuals with a positive TST or symptoms

compatible o TB disease.

Although the chest xray is a widely used diagnostic tool, the

ndings are not specic or TB and can be conused with other

diagnoses such as pneumonia or lung cancer. Although treatmentmay be initiated based on chest xray ndings alone, sputum

collection remains mandatory to provide denitive proo o disease.

The chest xray is the only way to ollow individuals who have had

previous abnormal chest xrays suggestive o old TB disease or latent

inection to determine i there are new radiological changes.

The Tuberculosis Screening Form HLTH 939 provides a guideline to

assess a client or a TB screening chest xray.

INDICATIONS FOR CHEST RADIOGRAPH

Tuberculin skin test positive 10 mm or greater on general screening

Contact o an active case o tuberculosis who has a skin test equal to or greater than

5 mm

Children under 5 years o age who are close contacts o an active case o inectious

TB

HIV positive individual who has a tuberculin skin test equal to or greater than

5 mm note: HIV positive clients should have a baseline chest xray

Immunocompromised individual who has a tuberculin skin test equal to or greaterthan 5 mm

Immunocompromised individuals, or IDUs, who are contacts o an active case

regardless o TST results.

Immigration medical surveillance requirements directed by TB Control

Suspect case with signs and/or symptoms o active tuberculosis

Individuals requiring TB screening who have had previous documented positive

tuberculin skin test

Individuals requiring TB screening who have had documented tuberculosis

Prior to starting preventative therapy or latent TB inection

Admissions at or over the age o 60 years to Adult Licensed Residential Community

Care Facilities preerably within one month o admission Urgent admission to Detox/Drug & Alcohol Treatment Programs

Those individuals starting TNF inhibitors

Others at the discretion o the Division o Tuberculosis Control


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A chest xray that has been done within the last six months should satisy any

o the above indications or a chest xray. There are some exceptions to this rule

which include:

Contacts o active TB

Individuals with signs and/or symptoms o active TB

Individuals with high/increased risk actors or developing active TB

and are TST or IGRA positive

NOTE:Contact TB Control or advice or these individuals.

A TB screening chest xray should not be done in place o a tuberculin sk in test

unless there is a contraindication to planting a skin test. Any exceptions should be

discussed with TB Control.

CONTRAINDICATIONS

Pregnant women during the rst two trimesters should avoid chest xrays i

possible. In these situations, tuberculin and sputum testing may be utilized or the

diagnosis o tuberculosis. I chest xrays are essential, appropriate shielding shouldbe used. Consult with TB Control.

X-RAY PROCESS

Eective April 1, 2009 MSP has assumed the nancial responsibility or the cost o

TB CXRs. In areas not serviced by stationary TB Clinics, the revised HLTH 939 orm

still acts as the requisition enabling the individual to obtain a CXR at a private

radiology clinic or hospital. The billing number 99996 is printed on the HLTH 939

orm and there is space or the individuals PHN. Steps o the CXR process include:

STEP 1: The health unit lls out the HLTH 939 and axes a copy to TB Control.

STEP 2: Individual takes white copy to a local radiology department and can keep

the pink copy or their own records.

STEP 3: I the chest xray is normal, the radiology department is instructed to send/

ax copy o the report and HLTH 939 orms to TB Control and the amily physician,

so we get 2 copies. I the screening is done or detox, long term care acility, school

or employment and the report is normal, then the individual may contact their

amily physician or results.

STEP 4: I the CXR is nondigital and abnormal the radiology department isinstructed to send the lm, HLTH 939, and report to TB Control. I the CXR is

digital and abnormal the radiology dept. will ax the report and HLTH 939 to TB

Control. TB Control will then contact them when they need to have the chest xray

transerred to 'the grid' to be read.


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STEP 5: I TB Control does not receive the CXR and/or report within three weeks o receiving

the initial HLTH 939, TB Control will ax the HLTH 939 orm back to the HU or appropriate

ollowup.

STEP 6: The respirologist at TB Control review the CXR, sputum results, and HLTH 939 orm

with recommendations made and sent to the HU and private physician.

Depending on a number o variables the turn around time rom when TB Control

receives an xray to when a report is sent out is unpredictable. Sending the CXR by

mail as opposed to putting it up on the grid delays the process. All reports must

be dictated, typed and then validated by the physician at TB Control. It can then

take up to 2 weeks beore a consult report is sent out. I you have not received any

inormation ater that time please contact TB Control.

For those individuals with signicant symptoms and i urgency o diagnosis is

required, please contact the Field Operations/TBSAC nurse to expedite the process.

For those needing to know at what stage the chest xray process is, they can contactthe appropriate radiology clerk at TB Control. See Organizational Chart.


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BACTERIOLOGICAL EXAMINATION OF SPUTUM

Bacteriological examination o sputum is the only diagnostic tool that

provides denitive proo a client suers rom active pulmonary tuberculosis

and is considered the "gold standard" or the diagnosis o TB disease. Without

bacteriological conrmation, drug sensitivities cannot be obtained making it

di cult to select an appropriate drug regime.

INDICATIONS FOR SPUTUM COLLECTION

Any client with a chronic productive cough greater than 3 weeks or other

symptoms compatible with active tuberculosis

PostLanding Immigration Surveillance clients

Any client with a positive TST and symptoms and/or abnormal CXR

HIV positive clients with a positive TST and/or symptoms

Any household contact with a positive TST and/or are symptomatic

consult with TB Control

For high risk clients who are unlikely to return their sputum containers, onthespot sputum collection is an appropriate strategy. For clients unable to produce a

sputum sample, please reer client to a centre that carries out sputum induction.

See Appendix P

SPUTUM COLLECTION

CLINICAL PRACTICE STANDARDS

Containers and requisitions are available rom the Provincial Laboratory;

Mycobacteriology requisition:http://www.bccdc.ca/NR/rdonlyres/BD6A7EAC8603482A9225FB9D8939657A/0/MycobacteriologyandTBRequisitionForm.pd

Container requisition: http://www.bccdc.ca/NR/rdonlyres/9CDC4B7D6587

4A17ACEEB6344FCA3285/0/RequisitionorSpecimenContainersSputumBottles.

pd

Label containers with the clients name and complete the requisitions. Containers

without labels are discarded.

Please ensure all sputum specimen requisitions or AFB are also sent ccd to

TB Control.


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Instructions to the client or obtaining sputum specimens should include:

Obtaining specimen in the morning upon rising beore eating

Taking a deep breath and cough to raise sputum rom the lungs

mucous or saliva rom the mouth is not useul

Using a hot luid drink to help stimulate sputum production i there

is diiculty in obtaining sputum

Collect the sputum specimen in the bottle supplied, ensuring the lidis tightly secured. Place the bottle in the ziplock bag provided and

ensure the bag is illed with absorbent material, e.g. cotton balls or

tissue

Obtain sputum samples on 3 consecutive mornings

Keep sputum samples in the rerigerator and return them as soon as

possible to the health centre or local public health unit or deliver y

to the Provincial Laboratory

The routine cooler and courier system may be utilized or sending

these specimens to the Provincial Laboratory

The specimens should not be sent during weekends or statutory

holidays In order to avoid remaining or too long a period in an overheated

post oice, sputum samples should be sent to the ollowing

laboratory complying with transport o dangerous goods

regulations:

SPUTUM REPORTING

SMEAR

Results are reported within 24 hours ater specimen is received at the laboratory.

They are not processed on the weekend and thereore specimens received on Friday

aternoon will be processed the ollowing Monday morning.

POSIT IVE SMEARAcid ast bacilli seen. This may indicate Non

tuberculosis Mycobacterium NTM. The majority o positive

smears in BC are NTM. Positive smears undergo PCR testing daily

Monday to Friday.

NEGATIVE SME ARNo acid ast bacilli seen. This does not rule out

active TB, but the likelihood the client has inectious TB is reduced.

Specimen is then cultured but not probed at this point.

Provincial Laboratory

BC Centre For Disease Control

655 W 12TH Avenue

Vancouver, BC, V5Z 4R4


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CULTURE

Cultures are incubated in both liquid and solid media or up to 8 weeks. Both

positive and negative smears are cultured.

POSIT IVE CULTUREGrowth o a mycobacterium. This may indicate

M. tuberculosis or a Nontuberculosis mycobacterium NTM.

Positive cultures will be probed once on either Tuesday or Thursday.

NEGATIVE CULTURENo growth on culture medium.

NOTE: Probes are tests to dierentiate Mycobacterium tuberculosis rom NontuberculosisMycobacterium NTM such as Mycobacterium avium MAC that do not cause inectioustuberculosis.

SENSITIVITIES

One to two weeks ater the culture grows, the sensitivity results will be available

through the provincial lab. The report will indicate which drugs the organism issensitive or resistant to and can infuence drug selection. The ollowing drugs are

initially tested: Isoniazid, Riampin, Ethambutol and Streptomycin. I resistance is

ound to either Isoniazid or Riampin, Pyrazinamide will be tested. I resistance

is ound to both Isoniazid and Riampin, second line drug sensitivities will

automatically be tested. Once the physician at TB Control has seen the results o

the sensitivities, prescription adjustments are made as needed and the appropriate

health care providers are inormed.

NOTE: For inormation on Genotyping please see Appendix M


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TB MYCOBACTERIOLOGYRESPIROLOGY SPECIMEN (SPUTUM/BRONCHOSCOPY)

AFB SMEARProcessed within 24 hours

CULTURE for MYCOBACTERIUMIncubation or up to 8 weeks

(Growth usually is between 36 weeks)

Due to issues ofreliabiity, not routinely

performed onnon-respiratory

specimens

Positive growth o

Mycobacteria to be

identifed

(Culture)

Negative, no growth

Approx. 15% o TB

cases in Canada were

culture negative

POSITIVESMEAR

NEGATIVESMEAR

PCR testing

POSITIVECULTURE

MTB Complex

PROBE RESULTSNon-tuberculosis

Mycobacterium (NTM)

PROBE RESULTS

ACCUPROBE

Results take 23 weeks ater

a positive culture

DRUG SENSITIVITY TESTING

NEGATIVECULTURE

M. TBcomplex NTM


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SECTION II ACTIVE TUBERCULOSIS

Case Management & Active Case Finding | 30

Flowchart: Management o An Active Case o Tuberculosis | 39


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CASE MANAGEMENT / ACTIVE CASE FINDING

DIAGNOSIS OF TB

Tuberculosis is a communicable disease caused by the bacteria Mycobacterium

tuberculosis. Humans are its primary host and it may reside anywhere in the body

although it is primarily a pulmonary disease. TB is a reportable disease under the

Health Act see Appendix B.

A diagnosis o active tuberculosis can be made when the ollowing criteria can be

established:

A positive culture growing Mycobacterium tuberculosis complex. These

specimens can come rom a variety o sources, including sputum, pleural

luid, and urine. A positive PCR result predicts a positive culture or M. TB

In the absence o a positive culture there are a number o indicators

which can lead to a diagnosis o tuberculosis.

Abnormal radiological evidence consistent with active

tuberculosis. Abnormal chest xrays, intravenous pyelogramIVP, and CT scans o chest and joints are useul tools in

arriving at a diagnosis.

Pathology indicating caseating granulomatous disease. Any suspect tissue

that is accessible to biopsy may be employed pleural, skin, lymph nodes,

and kidney biopsies. See Appendix B.

Clinical symptoms consistent with actie tuberculosis cough, night sweats,

ever, weight loss, hemoptysis, chest pain, atigue, decreased appetite.


While the responsibility or the control o communicable diseases lies with theMedical Health O cer, the clinical care o an active case o tuberculosis is

the responsibility o the clients personal physician, oten in consultation with

the physicians at TB Control and in collaboration with the local health units/

community health centres. Treatment is carried out based on the policies and

standards recommended by TB Control, who also supply the medication ree o

charge.

NOTIFICATION

Upon notication o an active case o tuberculosis, TB Control will notiy the

physician and the public health nurse. In consultation with a health care provider,the client will be inormed o the diagnosis. I the physician is unavailable it will

be the responsibility o the nurse to inorm the client. I the client has no amily

physician it will be incumbent upon the nurse to assist the cl ient to nd one who

will take responsibility or care.


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ASSESSMENT/ INFORMATION GATHERING

Ater client has been inormed o diagnosis it will be necessary to gather all

relevant medical inormation to determine the most eective treatment plan.

Included in this should be:

Clients drug allergies and weight.

An assessment o the clients social environment and those elements

which will aect issues o adherence and ability to selisolate. The Request or Inormation Form provided by TB Control should be lled

out and returned. This is inormation required by Health Canada.

Obtaining chest xrays, lab work, medical consultations and

orwarding them to TB Control will be the responsibility o the

Public Health Nurse and/or Community Health Nurse. Please reer

to Baseline Monitoring page 37.

Nurse to have patient sign an Access to Pharmanet Form which can

be downloaded o the website.

Included in the initial assessment should be a discussion o the

importance o contact tracing in reducing transmission and begin

collecting names or contact tracing. Please reer to section onContact Investigation.

EDUCATION

The PHN/CHN will meet with the client and amily to assess their needs and

provide education regarding TB disease and treatment o it. Client needs to be

inormed o common side eects o the medications, such as:

Orange urine, eces, sweat, tears rom Riampin

Peripheral neuropathy rom Isoniazid

Rashes

Hepatotoxic symptoms such as nausea and vomiting, abdominal

pain and yellow eyes or yellowing o the skin.

NOTE:For a more comprehensive list o sideeects reer to medication list in Appendix C.

Education will be necessar y or the duration o treatment and ongoing assessment

is important. When available, written educational material should be given to

the client see BCCDC website: http://www.bccdc.ca/discond/az/_t/Tuberculosis/

educmat/deault.htm.


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SELF-ISOLATION

Selisolation at home is required i a diagnosis o pulmonar y TB is made based on

smear positive or culture positive respiratory specimens.

Negative smear and Positive culture: requires selisolation or at least 2 weeks

Positive smear and Positive culture: requires selisolation or at least 2 weeks

ater the initiation o 1st line TB t reatment and 3 consecutive negative sputum

smears

There are a number o steps that can be taken to reduce transmission:

restrict public activities

no public transportation

restrict visitors to home

wear mask to all medical and lab appointments; surgical mask is

suicient

care givers wear N95 protective masks

respiratory hygiene cover mouth when coughing, spit into tissue,

tissue into garbage

When the client is unable to eectively selisolate based on the nurses assessment

then hospitalization is the preerred option. This decision should include the

amily physician, the client and the PHN/CHN. The MHO and TB Control should

be consulted i any problems arise around selisolation and/or hospitalization.

Sel isolation can be a very di cult time or both the patient and their amily.

Let the client know o things they can dosuch as get out or walks or resh

air. Encouragement, guidance, and reenorcement are oten needed during the

"isolation" period.

TREATMENT

Goals o treatment are to cure individual patients and minimize transmission

to other persons. Treatment is divided into two phases. The initial phase is the

intensive phase three or our drugs given and aims to quickly reduce the number

o rapidly dividing bacteria resulting in:

rapid reduction in symptoms

rapid reduction in inectiousness

reduction o the possibility o drug resistance

The second phase is reerred to as the maintenance or continuation phasetwo or three drugs:

elimination o any persistent bacteria not destroyed in

the initial phase

reduction o the possibility or relapse


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The importance o adherence cannot be overstated, especially in the intensive

phase to eliminate the potential or drug resistance. Exellent adherence limits the

chance o requiring a long and complicated, potentially 2nd line regimen and

promotes a successul outcome.

MEDICATIONS

All tuberculosis medications are provided without charge and distributed throughthe BCCDC Provincial Pharmacy. A TB physician must generate the prescription. Any

prescriptions written by a physician in the community must be orwarded and reviewed

by TB Control in order to obtain medication. Local pharmacies will not provide the

medication. Ater a prescription is written a copy will be axed to the health unit

and medications will be shipped. Most health units are supplied with starter units to

acilitate prompt initiation o therapy. Health units in many areas in the province are

also required to supply the local hospital with starter kits.

PHN/CHNs are required to administer medications to outpatients. I daily sel

administered treatment SAT is elt to be sae and appropriate the nurses will provide

the client with one month o medication only. I the client leaves the province or isaway on holiday, they will be provided with a maximum o two months medication to

take with them. I more medications are required the nurse should contact TB Control.

Clients who are on intermittent Directly Observed Therapy DOT should never be

given doses to seladminister because all doses must be directly observed by the PHN.

See Appendix K.

The decision regarding SAT vs DOT is oten recommended by the physicians at TB

Control in consultation with local healthcare providers.


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TABLE 2.1: TREATMEN T OF MYCOBACT ERIAL DISEASE IN ADULTS FIRST LINE MEDICATIONS

ANTI-TUBERCULOSIS DRUG INFORMATION

Drug Major Adverse Reaction Monitoring Remarks

Isoniazid INH

10 mg/kg up to 300 mg

Twice weekly: 15 mg/kg POusually 900 mg

Hepatotoxicity

Hypersensitivity

Peripheral Neuropathy

Symptoms

AST/SGOT

Phenytoin Dilantintoxicity

Pyridoxine 2550 mgmay be given to preventperipheral neuropathy.

With Disuliram Antabusemay lead to behaviour andcoordination disturbances.

Riampin

1020 mg/kg up to 600 mg

Twice weekly: 10 mg/kgusually 600 mg

Hepatotoxicity

Hypersensitivity

GI Upset

Thro mboc ytopeni a

Symptoms

AST/SGOT

Baseline CBC includingplatelet count

Decreases eectiveness othe contraceptive pill.

Increases ANTICOAGULANT drug requirement.

An orangered

discolouration o sweat,tears, may stain sotcontact lenses, urine,saliva, and eces.

Methadone dose may needto be increased.

Riabutin Rash, atigue, ever & sorethroat.

Visual disturbances such aseye pain.

Nausea, diarrhea, musclesor joint pain

See Riampin May cause tears, sweat,urine & eces to be brownorange and use alternativeorm o contraception iusing birth control pills.

Pyrazinamide

2030 mg/kg up to 2 g

Twice weekly: 5070 mg/kg

Hyperuricemia

Gastric irritation

Arthralgia

Hepatoxicity

Symptoms

AST/SGOT

Uric acid rise isunpredictable and does notrequire monitoring unlesshistory o gout.

Ethambutol

15 to 25 mg/kg

Twice weekly: 50 mg/kg

Retro bulbar neuritisrare at 15 mg/kg

Hypersensitivity

Symptoms

Baseline visual acuity andcolour perception monthly bymedication provider.

I on long term ethambutol,then pt should see anophthalmologist or anoptometrist when the abovenot available

Client should report anyvisual changes to physicianimmediately.


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TABLE 2.2: TRE ATMENT OF MYCO BACTER IAL DISEASE IN ADULTS SECOND LINE MEDICATIONS



Levaquin Rash, hives, or diicultybreathing

Irregular heartbeats orchest pain

Muscle, tendon or joint pain

Jaundice

Nausea, vomiting, diarrhea

Headache

Drowsiness orlightheadedness

Symptoms Avoid taking the ollowingwhen taking Levaquin:

Antacids containingAluminum, Calciumand/or Magnesium

Sucralate ulcermedication

Vitamins or mineralsupplements containingIron, Zinc or Calcium

Use caution when driving,operating machinery orperorming hazardousactivity.

Avoid excessive exposureto sunlight while takingLevaquin.

Avoid pregnancy andbreasteeding. I pregnancyoccurs, contact GP

Streptomycin

15 mg/kg up to 1 g

Twice weekly: 25 to 30 mg/kg usually 1 g

8th nerve toxicity especiallyvestibular

Hypersensitivity reactions

Paraesthesia, perioral notsigniicant

Mildly nephrotoxic

Symptoms

BUN

Creatinine

Hearing tests

Vestibular damagei.e. check balance and gait

I preexisting renalimpairment, monitorclosely.

Reduce dosage in olderclients

In children less than 14years, ater three weeksdaily therapy, reduce doseor give intermittently.

Not to be used duringpregnancy


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TABLE 2.2: TRE ATMEN T OF MYCO BACTERIAL DISEASE IN ADULTS SECOND LINE MEDICATIONS

(CONT.)



Ethionamide

15 to 30 mg/kg up to 1 g PO

GI disturbance

Hepatotoxic

Hypersensitivity

Symptoms

AST/SGOT

Bacteriostatic to bothintracellular andextracellular organisms.

Divided dose may help GI sideeects; has a metallic taste.

Avoid use during pregnancy.

Cloazamine Lamprene

100 mg daily

Discolouration o skintissue and body luids redcoloured to brownish blackand diminished sweating

and tear production.

Symptoms Bactericidal eect onMycobacterium bacilli.

Take with meals /ood.

Capreomycin

or dosage see Appendix C

8th nerve damage

Nephrotoxic

Ototoxic

Symptoms

Vestibular unction

Hearing tests

BUN

Creatinine

Bactericidal to bothintracellular andextracellular organismsand in cavities.

Use with caution in olderclients.

Rarely used i renal disease.

NOTE:See Appendix C or more comprehensive medication interaction table.

BASELINE MONITORING

The ollowing baseline measurements are necessary to properly prescribe

appropriate treatment and allow or subsequent monitoring requirements during

treatment:

Weight in kilograms

HIV serology consent, pre & postcounselling required

CBC with dierential, liver enzymes AST. For children under 16,

blood work is not required unless there are pre existing medical

conditions See pediatric appendix D

Visual acuity and red/green color discrimination i Ethambutol is

prescribed Schnelling chart or equivalent

Assess clients knowledge o medication side eects and encourage them

to contact physician or nurse immediately with any adverse events

Hepatitis A, B & C serology: at the discretion o the amily physician


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ONGOING MONITORING

AST ater two weeks o therapy, then monthly i AST is normal. In older patients

or those with underlying liver disease more requent monitoring o bloodwork at

the discretion o the TB physician or GP may be necessary.

Assess patient monthly or signs o adverse eects: liver toxicity, peripheral

neuropathy, or rashes.

Visual acuity or those on Ethambutol. I Ethambutol is continued beyond

2 months, an assessment by an ophthalmologist is required; or optometrist i theormer is not available. Followup should be done according to recommendations

by the ophthalmologist.

For those on Streptomycin, a monthly assessment o hearing and vestibular

unctioning should be undertaken.

Monitor or adherence pill counts; blister packs

For those clients who are smear positive, sputum should be collected every 2 weeks

until 3 negative smears have been reported see sputum algorithm page 28.

Collect three sputums monthly until there are 3 negative cultures

Chest xrays should be repeated every two months or pulmonary cases or as

otherwise recommended by TB Control.

For those clients with cavitary disease, repeat 3 sputums at the end o treatmentalong with the exit chest xray.

Report to TB Control any adverse side eects or abnormal lab values.

ADHERENCE

For those clients on seladministered therapy the PHN/CHN will enquire as to

any doses missed. This should be recorded on the Medication Reorder Form

along with any pertinent inormation such as side eects or any di culties with

treatment.

For those clients on Directly Observed Therapy the 'Record o Supervised TB

Medications' http://www.bccdc.ca/NR/rdonlyres/EBFC07282B364412B415

75AF04CD1ECB/0/HLTH832_RevJuly2010.pd shall be lled out as indicated

in the legend. This serves not only as the adherence record, but also the reorder

orm or more medication. A separate ax should be sent to report any other

inormation concerning treatment and issues. The appropriate TB Control nurse

consultant should be contacted by telephone with any urgent issues arising out

o treatment. I the TB nurse consultant is unavailable, contact the local GP with

concerns.

The initial reorder orm should be lled out ater the rst months medication isprovided so there is always one month supply available to ensure continuity o

treatment See Appendix Q.


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RECALCITRANT CLIENT

There may be clients who pose signicant challenges in complying with TB

treatment. Every eort should be made to establish a respectul trusting

relationship and i obstacles arise, clientspecic strategies can be developed to

resolve them. This relationship building will help determine successul completion

o treatment. Discussions should include all relevant participants including the

amily physician and TB Control. When a resolution is not possible, it is important

to keep the client inormed and educated about uture processes or decisions. The

PHN/CHN will be required to inorm the MHO who will make an assessment as

to the risk or the community at large and will give direction accordingly. The

MHO and TB Control should be inormed i there has been a two week period o

nonadherence. Ongoing eorts between the primary health care provider and the

client should be made to reestablish TB treatment.


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MANAGEMENT OF AN ACTIVE CASE OF TUBERCULOSIS

PULMONARY TB NON-PULMONARY TB

t Clinical evaluationt Sputum x 3 i productive cought Baseline CXR

tSmear or AFB ortCulture or MTB

tEnsure 3 sputum collectedor baseline (3 separate days

i possible)t3 sputums Q 2 weeks until 3consecutive negative smears

tQ monthly until 3consecutive negative cultures. A 2 month sputum collection

provides test o conversion

POSITIVE SPUTUM BASELINE SCREENING

t No isolation i Pulmonary TB

is excludedt Monthly clinical assessment

o symptoms, improvement andside eects o medications

t Radiological ollow-up as

recommended by TB Control

FOLLOW-UP

ABNORMAL X-RAY

t Recommend DOT (Directly Observed Therapy)t Requires prescription rom TB Controlt Standard Regime: Isoniazid, Riampin, Pyrazinamide, Ethambutol, Vit B6

MEDICATION

t Baseline: CBC, Dierential, ASTt AST at 2 weeks then:- - Q monthly or the frst 3 months i normal ollowed by: - Q 2 months or duration o treatment

- Abnormal values contact TB Controlt I on Ethambutol, baseline and monthly assessment

o visual acuity & colour discriminationt Children: bloodwork not routinely required on children


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GOALS OF CONTACT INVESTIGATION

Identiy any secondary cases o TB disease and initiate treatment as soon

as possible

Identiy newly inected individuals and oer preventative treatment and/or

appropriate ollowup

Identiy the source case when the index case is not the source case


Contact investigation is the responsibility o the Medical Health O cer MHO in

the relevant Provincial Health Authority. TB Control provides consultation and

works collaboratively with the designate o the MHO. The designate may be local

public health nurses, community health nurses or a communicable disease unit

within a regional health authority.

TB Control maintains a central registry o all contacts in order to track and

assist with coordination o contact ollowup. TB Control is responsible orcommunicating contact investigation inormation across health regions and

between provinces. It is important that all contact inormation is reported to

TB Control to ensure accurate and timely inormation is communicated to the

appropriate health care providers.

Public health nurses/community health nurses usually provide the rontline TB

screening o contacts and the ollowing inormation is provided to assist these

nurses in the decisionmaking required when undertaking a contact investigation.

TB Control is available or consultation throughout the contact investigation

process.

The physician at TB Control will review the sk in test and/or chest xray ndings o

all contacts and provide recommendations.

Contact investigation needs to be initiated as soon as possible ater a diagnosis o

active TB. The diagnosis o active TB and the initiation o contact investigation are

usually the result o:

Notiication that a respiratory specimen laboratory result is

smear positive or acid ast bacilli AFB and probe positive or

Mycobacterium tuberculosis MTB.

Notiication that a negative respiratory smear result is now culture

positive and/or probe positive or Mycobacterium tuberculosis.

In this setting the patient needs to submit a urther 3

sputum specimens to determine i they have become

inectious smear positive during the time it took or

the culture to grow.


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Active tuberculosis in young children is rarely inectious, but it is

usually a sign o a recent inection. Reverse contact investigation o

the childs close contacts should be done to identi y the source case.

A clinical diagnosis o active TB in the absence o laboratory

conirmation should be discussed with TB Control to determine the

need or contact investigation.

Nonpulmonary TB cases may require contact tracing and should be

discussed with TB Control.

PRINCIPLES TO GUIDE CONTACT INVESTIGATION

1. INFECTIOUSNESS OF THE SOURCE CASE:

Cases o laryngeal TB and smear positive pulmonary TB are considered most

inectious.

Cavitary pulmonary TB is usually very inectious.

Adults and adolescents are generally more inectious than children under 10 years old.

Duration o symptoms, particularly a cough, increases the risk o inectiousness.

Poor respiratory hygiene i.e. doesnt cover mouth when coughing and/or sneezingincreases the risk o spreading TB.

Forceul exhalation such as shouting or singing increases the risk o spreading TB.

Cases o nonrespiratory nonpulmonary TB are considered noninectious once

pulmonary TB has been ruled out ie. symptom inquiry, 3 sputum samples,

and chest xray with the exception o irrigation o open TB site wounds due to

possible aerosolization o TB bacteria.

Contact investigation o nonrespiratory TB is usually limited to household

contacts only, though investigation may expand depending on results o intial

CI. Children only require skin tests i asymptomatic. A chest xray is not required

in the absence o symptoms. Purpose o this screening is to locate the source

case.

2. PERIOD OF INFECTIOUSNESS

The period o inectiousness is usually considered to start at the time o onset

o cough. Individual clinical ndings may infuence the estimated period o

inectiousness. Consultation with TB Control is recommended i the client does not

report a cough.

The period o inectiousness ends when a client has received at least two weeks

o adequate treatment and has had 3 consecutive negative sputum smears. Thesputum specimens should be collected on 3 separate dayspreerably in the

morning.


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3. AIR SHARING EXPERIENCE

Tuberculosis is an inectious disease transmitted almost exclusively by the

airborne route. The risk o transmission depends on the concentration o inectious

droplet nuclei in the air shared by the case and their contacts. It is unlikely

that transmission o TB can occur outdoors. Indoor environments that are

small, conned and poorly ventilated can lead to an increased concentration o

tubercle bacilli in the air. In a closed circuit heating or air conditioning system,

recirculation o air tends to increase the concentration o tubercle bacilli and

increase the possibility o inection.

Another actor in the air sharing experience is the length o time spent in the same

indoor environment does not have to be home environment with an active TB

case. Contacts should be divided into categories according to the number o hours

spent with the source case per week.

TABLE 3.1: TYPE OF CONTAC T

TYPE OF CONTACT AMOUNT OF TIME WITH SOURCE CASE

Type 1 contactMore than our hours per week. Close household

contacts.

Type 2 contact

Two to our hours per week. Close non household

contacts who share the air space on an ongoing

basis i.e. close riends

Type 3 contactLess than two hours per week. Casual contacts

such as sports teams.

Contacts exposed during highrisk medical procedures are at high risk o becoming

inected. These procedures include:

Bronchoscopy

Sputum Induction

Autopsy

Intubation

4. SUSCEPTIBILITY OF THE CONTACT

Any individual with no prior TB inection is at risk o inection when in contact

with an inectious case o TB. Prior treatment o TB inection or disease is believed

to reduce the risk o reinection in individuals with healthy immune systems

although it does not completely remove the risk o reinection

The most susceptible contacts are those contacts most likely to be inected with


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the TB germ and those who are at a high risk o developing active disease once

inected. They include:

Children under 5 years o age

HIV positive

Immunocompromised

These highrisk contacts require a tuberculin skin test TST and a chest xray in a

contact investigation, regardless o TST result.

ASSIGNING PRIORITY FOR INVESTIGATION OF CONTACTS

The extent and order o contact investigation is based on the inectiousness o

the source case, extent o exposure to the source case, and the vulnerability o

the contact. Consultation with TB Control is advised to help establish a contact

investigation plan.

Highpriority contacts usually include household contacts, contacts 5 years old and

under, those contacts who are immunosuppressed, and contacts with symptoms o

TB disease.

CONCENTRIC CIRCLE APPROACH TO CONTACT INVESTIGATION

The concentric circle see Figure 1/page 45 approach to contact investigation is a

tool used to assist in determining who needs to be screened. Investigation begins

with close contacts o the source case. I close contacts have not been inected, it is

unlikely that casual contacts need to be screened.

I there is evidence o transmission o inection or secondary cases o active TB

in the close contacts o the case, then the next circle o type 2 contacts need to be

assessed and screened. Widening o the circle continues until there is no urther

evidence o transmission o TB inection.

Contacts screening may include; individuals, groups or locations, sports teams,

religious gathering places, a persons hobbies, area o employment, ater hours

activities, where a person sleeps i outside o the home, activities o daily living

pubs/bars/school or classes etc.

Although guidelines or TB contact investigations CI have been based upon

concensus expert opinion, recent studies have documented limitations in the

outcomes o traditional CI, including issues with contact identication, screening

completion and LTBI treatment initiation and completion. The problems with

standard CI are amplied in certain highrisk groups, such as homeless persons

and those struggling with issues o substance use who may be unable to recall

their contacts by name or other pertinent identiers.


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TYPE1TYPE2

TYPE3

Babysitter

Neighbours

ChurchGroups

Parties

Hunting

Clubs

Dances

LocalBar

Cofee

Shop

Bingo

Hall

VacationCamping

Public Transport

Friends

LunchRoom

RegularClients

Business Travel

Co-workers

Work

School

RegularMeetings

Tenants

SOURCE

CASE

RegularOvernight

Visitors

HouseholdMembers

SOCIAL NETWORKING & LOCATION-BASED SCREENING

The concentric circle approach to contact investigation has not been very successul

in homeless and street involved populations. These populations are highly mobile,

oten living unconventional liestyles. Street involved people do not always know

the names o people they socialize with, or only know their "street names".

There is evidence that social networking is a more successul approach with this

population, especially in an outbreak setting. Social networking is an approach

where key individuals and locations that are central to the spread o disease are

screened. In addition to screening close named contacts, locations where the source

case requents such as shelters or dropin centres are screened. This approach better

characterizes relationships with contacts and helps to understand unrecognized

patterns o disease transmission. Screening high risk locations should be indicatedin the contact box on the HLTH 939 orm.

A sample questionnaire is included in the appendix but it is important to realize

that the questionnaire may need to be modied to refect the community being

investigated. Including a person in the process who is knowledgeable about the

community is oten quite eective. TB Control can also provide the guidance in

implementation o network inormed CI.

FIGURE 1: CONTACT SCREENING / SOCIAL NETWORKING


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CONDUCTING A CONTACT INVESTIGATION

1. SOURCE CASE MEDICAL INFORMATION REVIEW

Laboratory results smear status; dates

Chest xray results

Symptoms

Onset o symptoms

2. INTERVIEW SOURCE CASE

The initial interview should occur as soon as possible ater the case is diagnosed

with active TB. This interview should include a review o patients symptoms to

veriy the period o inectiousness to identiy the patients contacts and to nd out

places where the patient spent time. It may take several interviews to obtain this

inormation.

The ollowing inormation should be obtained;

Contact with children and their ages

Contact with anyone who is immunosuppressed

Household contacts

Close nonhousehold contacts

Place o work, school, church and play

Other places where the patient may spend 2 or more hours/week

Social gatherings that may have occurred during the period o

inectiousness, such as weddings, unerals and community events.

Does the source case know anyone with signs and/or symptoms o TB?

Has the index case been traveling during the estimated period, or in

the last 2 years, o inec tion? I yes, obtain details o trip, including

means o transportation.

It is important to gather as much detailed inormation about the contacts as

possible to assist in the screening process. This inormation should include names,

dates o birth, addresses, and phone numbers. It may be useul to ask the patient s

permission to interview amily members or close riends to assist in gathering

contact inormation.

Assure the patient that their diagnosis o TB is conidential and will not be shared

with their contacts. Give the patient the choice o inorming their own contacts.

Inorm the patient that i their contacts have not reported or testing within a week

a public health nurse or community health nurse will ollowup with the named

contacts.


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The interviewer needs to be sensitive to the concerns and belies that a patient may

be experiencing about having been diagnosed with active TB. The interview should

include education and inormation about active tuberculosis and its treatment.

The interview should be done in a respec tul manner that helps to develop a

relationship o open communication. The interview may need to take place over

a period o time. Clients should be advised to contact PHN/CHN with additional

inormation names, locations that become apparent as t ime goes by.

A preliminary list o contacts should be established within 3 days see Time Frame

or Contact Tracing page 54 o the diagnosis o an active case o tuberculosis and

sent to TB Control on a Followup Contact Assessment TB Control HLTH 836 s orm.

I public health wishes, they can develop their own orms to meet their particular

needs but must capture the inormation listed on the HLTH 836 s orm.

3. FIELD INVESTIGATION

A eld visit may be benecial to assess the air sharing environment o the source

case. Environmental characteristics o the congregate setting should be assessed

and may assist in determining appropriate site screening. Size o the space, airfow,number o windows are some o the important components in the assessment. The

visit may also provide additional inormation about potential contacts.

4. PRIORITY OF CONTACT SCREENING

All the inormation gathered in the above three steps should be used to determine

the probable risk o transmission. This assessment should then guide the priority

and initial extent o contact screening.

In almost all cases o active tuberculosis, the high priority contacts or screeninginclude household contacts, children under 5 years o age, immunosuppressed

individuals, and contacts with reported symptoms o TB.

Based on the initial risk assessment o transmission, a plan needs to be established

or priority contact screening. Every attempt should be made to ollow the

established plan in order to use personnel resources where they are most needed

and to evaluate the outcomes o the contact circle that is being screened.

In small communities there can be the potential or "panic" and nurses may be

overwhelmed by the volume o casual contacts, and people who are not sure they

are contacts, wanting to be tested. In these situations, it is sometimes advisableto schedule one or two screening clinics to diminish the anxiety o the casual

contacts, while allowing the nurses to concentrate, on the priority contacts.


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CONTACT EXAMINATION PROCEDURES

INTERPRETATION OF TST RESULTS IN CONTACT SCREENING

TABLE 3.2: INT ERPRETING TS T RESULTS IN CON TACT SCREENING

SIZE OF INDURATION INTERPRETATION ACTION

0 to 4 mm Negative Repeat TST in 8 Weeks

5 mm or more PositiveSend or chest xray

PRIORITY SCENARIOS:

1. CHILDREN UNDER 5 YEARS OF AGE

Children under 5 years o age have an increased risk o developing active TB

primary disease once they have been inected with TB. They are also at risk o

developing miliary TB or TB meningitis. Consequently, it is important to protectthese children with primary prophylaxis during the incubation period o TB

inection.

TB Control should be notied immediately o all children under 5 years o age who

are close contacts o the source case. Initial testing o these children will include

a tuberculin test as well as a chest xray. A HLTH 939 orm should be initiated.

I the TST is negative 0 to 4 mm and the chest xray is normal, the child may

be recommended to start on primary prophylaxisIsoniazid syrup, or crushed

tablet, to be prescribed according to the childs weight. The child will have a repeat

tuberculin skin test in 8 weeks.

Children under six months o age may not be able to mount a TST response;

thereore primary prophylaxis Isoniazid treatment may be continued until a

repeat TST at six months o age. I this repeat skin test is negative, Isoniazid can be

stopped. I this repeat sk in test is positive 5 mm or greater the child will continue

preventative therapy or a total o 9 months.

Guidance rom TB Control should be sought or all children under 5 years o age.

The TB Control physician will decide i a chest xray is required.

Inants will need to be weighed regularly to ensure that Isoniazid dosage is

adjusted to accommodate weight gains.

NOTE:Please see Appendix D or more inormation on Pediatric TB.


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PEDIATRIC PRIMARY PROPHYLAXIS OF CHILDREN

PRIMARY PROPHYLAXISFor Children < 5 years o age who are:

MEDICATION

tClose contact to active case of TBtContact TB Control; initiate HLTH 939

tNegative TST at baselinetNormal chest x-ray

tAsymptomatic

tPrescribed & dispensed by TB ControltStandard regime: Isoniazid x 2 months minimum

tChilds weight required to determine dose

BLOOD WORK

tNot required or children


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2. IMMUNO-SUPPRESSED CONTACTS

HIV positive and other immune suppressed contacts should have TST and a CXR

as soon as possible. I these contacts are symptomatic, 3 sputum specimens or

AFB should be submitted to the laboratory. These contacts may be oered primary

prophylaxis i their initial TST is negative 04mm and chest xray is normal.

A repeat TST should be done in 8 weeks. I the second TST is positive 5 mm or

greater the individual will continue preventative therapy or a total o 9 months.

I the second TST is negative, it is possible the individual may need to continue

preventative therapy or a total o 9 months. The decision to stop or continue

preventative therapy is based on the individuals immune response and i it is

deemed capable o mounting a response to tuberculin. This will be assessed on an

individual basis in consultation with TB Control and oten the clients specialist.

Notiy TB Control o all HIV positive and other immune suppressed contacts. I

CD4 counts are available please ax to TB Control.

EXAMINATION OF ALL CONTACTS

A HLTH 939 orm must be completed or each contact and sent to TB Control. It is

important to ll out all sections o the HLTH 939 to assist the TB physician to make

appropriate individual recommendations or each contact.

Assessment o each contact includes:

Demographics o the contact

Type o contact details can be written on HLTH 939 or axed on a

separate sheet

TB number o source case or PHN is TB # not available

Medical risk actors or developing TB disease

Symp

BCCDC TB ManualRevisedFebruary 2012

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